ARCHETYPE Auscultation of breath sounds (openEHR-EHR-CLUSTER.auscultation_breath.v0)

ARCHETYPE IDopenEHR-EHR-CLUSTER.auscultation_breath.v0
ConceptAuscultation of breath sounds
DescriptionFindings observed during the auscultation of breath sounds.
UseUse to record a narrative description and clinical interpretation of the findings observed during the auscultation of breath sounds. This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the OBSERVATION.exam, CLUSTER.exam-lung or CLUSTER.exam-abdomen archetypes, but can also be used within other ENTRY or CLUSTER archetypes, where clinically appropriate. The CLUSTER.exclusion_exam archetype can be nested within the 'Examination not done' SLOT to optionally record explicit details about the examination not being performed. Use to incorporate the narrative descriptions of clinical findings within existing or legacy clinical systems into an archetyped format, using the 'Clinical Description' data element.
MisuseNot to be used for recording the clinical history - use specific OBSERVATION and CLUSTER archetypes. For example OBSERVATION.story and CLUSTER.symptom_sign.
PurposeTo record a narrative description and clinical interpretation of the findings observed during the auscultation of breath sounds.
References
Copyright© openEHR Foundation
AuthorsAuthor name: Keisha Barwise
Organisation: openEHR Foundation
Email: keisha.barwise@openehr.org
Date originally authored: 2025-05-13
Other Details LanguageAuthor name: Keisha Barwise
Organisation: openEHR Foundation
Email: keisha.barwise@openehr.org
Date originally authored: 2025-05-13
Other Details (Language Independent)
  • Licence: This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/.
  • Custodian Organisation: openEHR Foundation
  • Original Namespace: org.openehr
  • Original Publisher: openEHR Foundation
  • Custodian Namespace: org.openehr
  • MD5-CAM-1.0.1: C27D920B3D313B1041C153D5B1DD8D1F
  • Build Uid: 918720a6-e302-4cd6-a13d-e8d0d467da46
  • Ip Acknowledgements: This artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyrighted material of the International Health Terminology Standards Development Organisation (IHTSDO). Where an implementation of this artefact makes use of SNOMED CT content, the implementer must have the appropriate SNOMED CT Affiliate license - for more information contact https://www.snomed.org/snomed-ct/get-snomed or info@snomed.org.
  • Revision: 0.0.1-alpha
Keywordsbreath sounds, auscultation
Lifecyclein_development
UIDce13c28e-45ab-480c-91e6-09c4c45f046c
Language useden
Citeable Identifier1246.145.2842
Revision Number0.0.1-alpha
items
Body siteBody site: Identification of the area of the body under examination.
For example examination of a specific area of the lung. If the body site has been fully identified in the parent archetype in which this archetype is nested, this data element becomes redundant.
Structured body siteStructured body site: A structured description of the area of the body under examination.
If the body site has been fully identified in the parent archetype in which this archetype is nested or in the 'Body site' data element, this SLOT becomes redundant.
Include:
openEHR-EHR-CLUSTER.anatomical_location.v1 or
openEHR-EHR-CLUSTER.anatomical_location_circle.v1 or
openEHR-EHR-CLUSTER.anatomical_location_relative.v2
Clinical descriptionClinical description: Narrative description of the auscultation findings.
PresencePresence: The presence or absence of any breath sounds heard on auscultation.
  • Present
  • Absent
IntensityIntensity: The relative volume or loudness of all breath sounds compared to what is expected.
  • Increased [The breath sound is louder than expected over the area of lung being auscultated.]
  • Normal [The breath sound is heard at the expected intensity over the area of lung being auscultated.]
  • Decreased [The breath sound is less intense than expected over the area of lung being auscultated.]
  • Absent [The breath sound is not heard over the area of lung being auscultated.]
TypeType: The type or character of the breath sounds heard on auscultation.
For example: Vesicular; Bronchial; Bronchovesicular; Tracheal.
Adventitious breath soundAdventitious breath sound: Details about an abnormal breath sound heard over the area of lung being auscultated.
Breath soundBreath sound: Name of the abnormal breath sound.
Choice of:
  •  Coded Text
    • Wheeze [A continuous, high-pitched sound resulting from airflow through narrowed or compressed airways.]
    • Rhonchi [A low-pitched sound caused by airflow through large airways with secretions or obstruction.]
    • Stridor [A high-pitched sound resulting from turbulent airflow due to upper airway obstruction.]
    • Fine crackles [A discontinuous, high-pitched sound produced by sudden opening of small airways.]
    • Coarse crackles [A discontinuous, low-pitched sound produced by air passing through larger airways with fluid or secretions.]
    • Pleural rub [A grating sound generated by inflamed pleural surfaces rubbing against each other.]
  •  Text
PresencePresence: The presence or absence of an identified abnormal sound.
  • Present
  • Absent
IntensityIntensity: The volume or loudness of the identified breath sound.
  • Soft [The abnormal sound is faint and hard to hear.]
  • Moderate [The abnormal sound is clearly heard but not dominant.]
  • Loud [The abnormal sound is easily heard and prominent.]
PhasePhase: The timing of the sound within the whole breathing cycle.
  • Inspiratory [The abnormal sound is heard during inhalation.]
  • Expiratory [The abnormal sound is heard during exhalation.]
  • Biphasic [The abnormal sound is heard during both inhalation and exhalation.]
TimingTiming: The timing of the sound within the specified 'Phase' of the breathing cycle.
  • Early [The added breath sound occurs at the beginning of either the inspiratory or expiratory phase.]
  • Mid [The added breath sound is heard during the middle portion of either the inspiratory or expiratory phase.]
  • Late [The added breath sound occurs near the end of the inspiratory or expiratory phase.]
Clinical descriptionClinical description: Narrative description about the identified breath sound.
Vocal resonanceVocal resonance: Details about vocal resonance heard over the area of lung being auscultated.
IntensityIntensity: The relative volume or loudness of the transmitted sounds compared to what is expected.
  • Increased [The transmitted vocal sound is louder than expected in the area of the lung being auscultated.]
  • Normal [The transmitted vocal sound is heard at the expected intensity in the area of the lung being auscultated.]
  • Decreased [The transmitted vocal sound is quieter than expected in the area of the lung being auscultated.]
  • Absent [No transmitted vocal sound is heard in the area of the lung being auscultated.]
TypeType: The type or character of transmitted sound heard.
  • Aegophony [A change in the quality of the spoken voice over the chest wall, in which the sound "ee" is heard as a nasal "ay".]
  • Whispered pectoriloquy [Increased clarity and loudness of whispered speech heard over the chest wall.]
  • Bronchophony [Increased clarity and loudness of spoken voice over the chest wall.]
Clinical interpretationClinical interpretation: Single word, phrase or brief description that represents the clinical meaning and significance of the auscultation findings at the body site.
For example: 'No abnormality detected' or 'Consolidation present'. Coding of the 'Clinical interpretation' with a terminology is preferred, where possible.
Examination not doneExamination not done: Details to explicitly record that this examination was not performed.
Include:
openEHR-EHR-CLUSTER.exclusion_exam.v1
CommentComment: Additional narrative about the auscultation findings at the body site, not captured in other fields.
Other contributorsHeather Leslie
CCIO
openEHR Foundation
heather.leslie@openehr.org
Translators